you take insulin?’ asks my colleague.
‘Oh, yes … but just a little injection before each meal.’
Aha! This is something I was warned about in training, and now it’s happening during my very first call-out. It is in fact extremely common for patients who take regular medication to deny it with full conviction when asked. I can’t offer any explanation for this. It seems as if, for many people, taking medication regularly becomes routine, like brushing their teeth every morning. So they consider their pills, or even the contents of a syringe, no differently from the spoonful of sugar they take in their coffee or tea. It is certainly not deliberate deception on the patients’ part — but in an emergency situation it can be deadly dangerous.
Stefan continues to question the patient about his medical history. ‘Have you ever had difficulty breathing before, or have you been ill with anything other than a cold and your diabetes?’
‘No, just diabetes!’ answers the patient resolutely.
Yet suddenly, as if from nowhere, his wife joins the conversation. She has slowly but surely shuffled down the hallway into earshot. ‘Tell them about your angina!’ she shouts. ‘Angiiiiinaaaa!’
With a slightly annoyed roll of his eyes, the elderly man tells us he was diagnosed with angina pectoris* two years before, but no longer takes medication for it. He reports intermittent difficulty breathing, but says it always went away again and has never been this bad.
While Sina places the blood-pressure cuff on his arm, I offer him the oxygen mask, which he literally snatches from my hand and presses over his mouth and nose. I decide to begin with eight litres per minute. Using a pulse oximeter attached to his finger, I measure the oxygen saturation of the patient’s blood. It seems pretty normal at the moment. But the man’s blood pressure and heart rate are both high. This may be due to stress, or it could have a much more serious cause. Chest pain, breathing difficulties, and heart problems in the past — all the alarm bells are ringing.
My colleague takes an ECG reading while I prepare an infusion. As soon as the first lines appear on the ECG, our suspicions are confirmed: it’s a heart attack!
Less than two minutes have passed since we arrived, and the patient’s condition is rapidly deteriorating. He’s having increasing difficulty breathing, and although I have turned the flow up to maximum, the oxygen saturation of his blood is plummeting. My colleagues do everything in their power to help him, while I feel rather at a loss. I follow my colleagues’ instructions, preparing a needle and antiseptic for an intravenous catheter. As Stefan prepares to insert the needle, the man, now pale and blue-lipped, looks at me with fear in his eyes. His blood pressure is falling, his ECG is becoming ever more erratic, and the atmosphere is growing ever more sombre.
Sina speaks to him, trying to reassure him; the man never takes his eyes off me. His look screams, ‘Help me!’
This is the worst feeling of my life so far. Inside my head, there’s complete turmoil. What else can we do for him? Did my grandfather suffer like this? The man’s gaze seems to pierce right through me. For a brief moment, I have the feeling that it’s my own grandfather looking at me. Then, all of a sudden, the old man keels over to one side and loses consciousness. Before he can slide off the couch, Stefan catches him and lowers him carefully onto the carpet.
A quick check: breathing — yes; conscious — no. Place the patient in the recovery position and prepare to unblock the airways by suction if necessary; I remember my textbooks, and act accordingly. Get suction pump out of the rucksack, attach suction tube. A quick test and we’re all set. If the man should start to vomit, I can quickly jump in with my pump.
The man’s wife sits silently on a chair by the living-room door. We hear the howl of a siren coming from outside: the emergency doctor has been called and is on his way. Thank God for that! Sina asks the lady to go open the door. Just as she leaves the room, it happens: there’s a piercing beeping noise, and the lines on the ECG begin to jump crazily. Ventricular fibrillation! A condition in which there is rapid and uncoordinated contraction and relaxation of the muscles of the ventricles of the heart, making it unable to pump blood.
Stefan immediately begins CPR (cardiopulmonary resuscitation) procedures, Sina prepares the defibrillator and I unpack the intubation equipment. At that moment, the emergency doctor enters the room. My colleague quickly fills him in on the situation, and then off we go: the man is defibrillated, which means we try to force his heart back into a normal rhythm with strong electric shocks. At the same time, we insert a tube into his trachea (windpipe) and ventilate him artificially, as well as giving him all sorts of drugs. For more than three hours, we try to keep him alive, but without success. This is my first emergency call-out, and it has ended in disaster.
When we return to the station later that evening, the nightshift team is already there, ready to take over. My colleagues hand the ambulance over to them as I dejectedly make my way home. I can’t help wondering if I made some mistake, if there was anything more I could have done. Is this really the right job for me? Can I bear to watch people dying on a regular basis?
On arriving home, I study all the chapters on heart attacks in my collection of books for the umpteenth time, trying to find out where I might have gone wrong. This feeling of insecurity is new for me. It is some time before I realise: we didn’t make any mistakes. For better or worse, I have to come to terms with the fact that even a trained paramedic can’t save everyone.
Of Dragon Boats and (Oar) Strokes
A healthy human heart is about the size of a fist. Depending on body size and fitness level, it can weigh between 230 and 280 grams (8–10 oz) in an adult. It’s made up mostly of heart-muscle cells, known to doctors as cardiomyocytes. There are two types of heart-muscle cell, and — a little bit like the staff on a hospital ward — there is a strict hierarchy between them.
The first type is the cells of the working heart muscles, which are responsible for making the heart beat by tensing and relaxing. They may be in the majority, but they can’t escape the tyranny of the other, minority cell type: those of the heart’s electrical-conduction system. Just like a pacemaker, these cells generate an electrical impulse and conduct it to the cardiomyocytes to cause the heart to beat. The two types of cell are like the drummer dictating the stroke and the rowers in a traditional Chinese dragon boat.
These two cell types differ not only in their function, but also in their appearance. The pacemakers are somewhat larger than their colleagues, and have a ‘pale and interesting’ look about them. With impressive regularity, they make sure the heart beats at a constant rate — between 60 and 80 times a minute at rest. Provided, that is, that they are healthy and functioning as they should.
Unlike some of the other organs of our bodies, the heart has very limited regenerative capabilities. Compared to the liver, which can renew its cells exceptionally quickly, and even the lungs, which manage the same trick but at a much more leisurely pace, the heart is at the bottom of the regeneration league. Fewer than half the heart’s cells are replaced over the course of an entire human life.
Despite this, the heart has all the cardiomyocytes it needs. The left ventricle alone is made up of an estimated six billion cells. If you were to look at each one of these cells through a microscope for half a second, you would have to spend almost 200 years at the eyepiece. That’s without counting breaks for sleeping, eating, or satisfying other natural needs. Wow! That’s a lot of cells! This naturally raises the question of where the heart gets all the energy it needs to pump some five to six litres (1–1.5 gallons) of blood per minute, even
